A nurse is preparing for an Incoming storm. Which of the following clients should the nurse recommend for discharge planning?

This question focuses on identifying suicide risk factors in a client experiencing severe depressive symptoms after major life stressors. The client has experienced the loss of a long-term relationship and employment, both of which are significant psychosocial triggers for depression and suicidal thinking. Progressive withdrawal, hopelessness, flat affect, and verbal expressions about not wanting to live are major warning signs requiring immediate intervention. Early recognition of suicidal ideation is critical because emotional distress can rapidly progress to self-harm or suicide attempts without timely support and safety measures.

Rationale for correct choices:

• Suicidal ideation: The client demonstrates multiple classic indicators of suicidal ideation, including hopelessness, social withdrawal, worthlessness, and the statement, “I wish I weren’t here.” Verbalizing a desire not to live is a significant warning sign that must always be taken seriously. The initiation of one-on-one observation further supports concern for self-harm risk and indicates the need for close monitoring and suicide precautions. Clients experiencing major losses are particularly vulnerable to suicidal thoughts during depressive episodes.

• Statements of hopelessness and wishing not to be alive: Hopelessness is one of the strongest psychological predictors of suicide risk because it reflects a belief that circumstances will not improve. The client’s statements reveal despair, emotional exhaustion, and passive death wishes, all of which are concerning for suicidal ideation. Combined with tearfulness, isolation, and feelings of worthlessness, these statements suggest significant emotional instability. Such findings require immediate assessment of suicidal intent, plan, and access to means.

Rationale for incorrect choices:

• Acute stress disorder: Acute stress disorder occurs after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. Symptoms typically include dissociation, intrusive memories, hypervigilance, and avoidance behaviors shortly after the trauma. Although this client is under emotional stress, the presentation is more consistent with depressive symptoms and suicide risk rather than trauma-related stress pathology. No evidence of dissociative or trauma-reexperiencing symptoms is present.

• Borderline personality disorder: This is characterized by chronic interpersonal instability, impulsivity, fear of abandonment, unstable self-image, and recurrent self-destructive behaviors beginning in early adulthood. The scenario does not describe a long-standing maladaptive personality pattern or impulsive relationship instability. Instead, the symptoms appear linked to recent situational losses and depressive reactions.

• Recent increase in appetite and energy level: An increase in appetite and energy level is not documented in this scenario and would not directly support suicide risk in the way hopeless verbalizations do. In some depressed clients, sudden increased energy after severe depression can raise concern for suicide because the individual may gain energy to act on suicidal thoughts. However, this client instead demonstrates lethargy, withdrawal, tearfulness, and hopelessness.

• Participation in group activities with peers: Participation in group activities generally suggests social engagement and willingness to interact with others, which are protective rather than high-risk behaviors. The client in this scenario is withdrawn from family and friends and remains isolated in bed. Social isolation commonly worsens depression and increases suicide risk by reducing emotional support systems. Therefore, active peer participation would not support the identified concern.

Accurate measurement of a tympanic temperature depends on correct alignment of the ear canal with the tympanic membrane to ensure proper infrared detection of body temperature. The procedure requires appropriate positioning of the ear to straighten the external auditory canal, allowing the probe to obtain a reliable reading from the tympanic membrane. Proper technique is especially important in clinical settings where temperature trends are used to monitor infection or inflammatory processes.

Rationale:
A. Positioning the client facing the nurse is not required for tympanic temperature measurement. While proper positioning can improve ease of access, it does not influence the accuracy of the reading. The key determinant of correct technique is proper alignment of the ear canal rather than client orientation.

B. Pointing the probe posteriorly is incorrect because the probe must be directed toward the tympanic membrane, not away from it. Misalignment of the probe can result in inaccurate temperature readings due to improper infrared detection. Correct technique requires gentle insertion following the natural curvature of the ear canal.

C. Pulling the pinna up and back is the correct technique for an adult when measuring tympanic temperature. This action straightens the external auditory canal, allowing the probe to align directly with the tympanic membrane for accurate measurement. Proper positioning ensures reliable detection of infrared heat emitted from the eardrum.

D. Inserting the probe with a straight forward motion is incorrect because the ear canal is not a straight structure. A direct forward insertion can cause discomfort, inaccurate positioning, and unreliable readings. The probe should follow the natural angle of the canal after proper manipulation of the pinna.